The first-ever global study of sexual and reproductive health - to be published in the medical journal The Lancet starting this week - shows a picture of declining financial support, increased political interference and an overall reluctance to tackle threats to sexual and reproductive health.
The evaluation, coordinated by the World Health Organization (WHO), shows that the level of disability and premature death due to sexual and reproductive health is huge and increasing. Unsafe sex is the second most important cause of illness and death in developing countries and ninth in developed countries.
The analysis reveals a picture of growing unmet needs and neglect. More than half a million women die as a result of complications in pregnancy and childbirth every year. Access to contraception has increased worldwide but there are still an estimated 120 million couples who do not get the contraceptives they would like or need. An estimated 80 million women have unintended or unwanted pregnancies each year. 45 million end in abortion. WHO figures quoted in the survey show that there are 19 million unsafe abortions carried out each year, resulting in around 68 000 deaths and millions of injuries and permanent disabilities.
"These statistics represent an appalling catalogue of human tragedy," says Joy Phumaphi, WHO Assistant Director-General for Family and Community Health. "Far from making progress we seem to have been going backwards since the notion of reproductive health was born in Cairo in 1994. The issue is dropping down the international agenda and governments seem to be reluctant to tackle this most fundamental threat to health and well-being."
Several examples of this decline are quoted in the study. Between 1995 and 2003, donor support for family planning fell from US$ 560 million to US$ 460 million. According to the survey, family planning services in Africa need an extra US$ 70 million just to achieve the mid range of fertility projections recommended by the United Nations. Additionally, funding for contraceptive development has declined compared to microbicide research for HIV/AIDS. As well as surveying the statistical evidence on the increase in sexual and reproductive ill-health, the series highlights the importance of understanding sexual behaviour.
The survey of data from 59 countries shows that contrary to common belief, there is no universal trend to earlier first sexual intercourse. However, later marriages mean that there are more opportunities for premarital sex which is resulting in high rates of unintended pregnancy, unsafe abortions and sexually transmitted infections among the young.
According to Dr Paul Van Look, Director of Reproductive Health and Research at WHO, "Sexual behaviours and norms vary enormously around the world and unfortunately many people, including politicians and even health professionals, are uncomfortable dealing with such matters. This survey sounds an urgent alarm that if we do not address sexual and reproductive health openly and directly the toll of death and disability will remain with us for many years to come."
Given the diversity of sexual and reproductive behaviours revealed by the study, the authors call for a mix of prevention strategies and caution against quick fixes and a "one size fits all" approach. They call for greater efforts to tackle the links between sexual and reproductive ill-health and poverty, gender inequalities and negative social attitudes.
The Lancet Series on Sexual and Reproductive Health will be published in the coming weeks. The series will focus on issues such as adopting a public health approach to sexual and reproductive behaviours to reduce death and disability from unsafe sex, the impact of unsafe abortions, and the need to prioritize sexual and reproductive health, family planning and contraception to achieve the Millennium Development Goals.